This is the heading of a recent paper out of Belgium, where the authors looked at recent advances in pain neuroscience. and how it can be applied in the intervention for chronic lower back pain. This information can also be applied to other chronic pain conditions, in particular involving the spine from the neck down to the pelvis.

In the last couple of decades, we have become aware of the existence of central (and peripheral) sensitization of the nervous system, which may significantly add to the perception of pain and disability. Recent studies in neuroscience have added to this body of knowledge. Unfortunately, treatment options today seldom take such knowledge into consideration, therefore often producing disappointing results.

Central sensitization refers to amplified activity of part of the nervous system within the spinal cord and brain, responsible for our perception of pain. This makes movements and activities excessively painful, which under more normal circumstances would not cause such a response. We also may see a reorganization of neurons within the brain, and increased activation in areas of the brain that normally would not be activated. This often produces a diffuse spread of pain perception to other and distant body regions, which usually can not be explained by traditional anatomical charts..

Common is also increased anxiety, and fear of movements or activities causing pain, due to this reorganization of our central nervous system. Sleep disorders often follow as well, which further worsens our ability to tolerate the pain. It can be a viscous cycle, which may have a severe impact on a person’s life.

Not everyone who has chronic pain will develop such central sensitization, however. Researchers estimate that approximately 25% of people with chronic low back pain develop this condition. It has been reported after whiplash injuries as well. The good news is, that increasing evidence shows that the changes in the brain are not permanent, and can be reversed by effective intervention, according to the authors from Belgium..

When we develop such pain sensitization, we become fearful of certain movements and activities, to the point that even just thinking about them, may elicit a pain response. Therefore, one strategy often recommended, is to try very hard not to think about the pain, or what activities may trigger it, in order not to continuously activate these abnormal nerve pathways in the brain. One guideline is to not think about the pain more than 5-6 times per day total, which is very difficult to do when we always are in pain. People who are analytical in nature, e.g. the engineer personality, tend to have an in particular difficult time not thinking about the pain, and what can trigger it.

What is important to realize, is that most of the activities or movements that we become afraid of, do not cause any injury or irritation to our tissues (e.g. joints, discs, ligaments or muscles) even though we experience pain with such movements. People with central sensitization therefore report pain, which is disproportionate to what you would expect, given their condition or injury. This is very important to understand, because it is counter intuitive.

Effective treatment almost always must start by applying a “biomedical approach”, e.g. to address compressed or irritated peripheral nerves if present, loss of joint motion, secondary muscle guarding, loss of coordination, and loss of muscular function (e.g. endurance, strength and flexibility), as well as weakness of involved tissues. This can be accomplished with manual therapy approaches, and specific and gradually progressed exercise therapy. Appropriate medical treatment also fits in here

However, when we develop central sensitization, this is often not enough. We must address the changes that have occurred within our brains. The first step, is to understand how the described neuroscience works, in order to move forward from there. The authors out of Belgium recommend to then start cognitive functional therapy, or cognition-targeted exercise therapy. The goal is to gradually desensitize the central nervous system and create new neural pathways within the brain. The concept is to include graded and repeated exposure to fearful movements, in order to generate a new memory of safety in the brain.

To do this, you pick a number of movements which you are fearful of, and perform them a set number of times (e.g. 5-10 times), and gradually increase the exposure per day, over time. This program must be set up by a proffessional, such as a well trained physical therapist. The movements are performed regardless of symptoms. The same approach can be applied to daily physical activities such as walking, bicycling, gardening, grocery shopping, cooking etc..The progression needs to be monitored and supervised, and the neuroscience be reinforced. The whole approach also gradually changes from “treating illness” (which reinforces the sensitization), to promoting wellness (which can aid in restoring normal neural pathways in he brain). Therefore, long term, too much “hands on treatment” can make these people worse, as it tends to bring focus back onto the pain.

Insomnia is also very common in chronic pain conditions, which must be addressed, but won’t be discussed in detail here.. Suggested treatment may include changing negative thoughts about sleep, sleep hygiene, sleep restriction therapy, and teaching relaxation skills, and meditation.

The topic discussed in this newsletter is complex, but unfortunately very common, and for treatment to be successful, there must be full cooperation between the clinician and the patient, who must also have a positive attitude and expect a positive outcome. We can call this “mind games”, but today we know that we are actually re-routing the neural pathways in our brains.